Sie sind auf Seite 1von 60

Cardiovascular diseases (CVD)

Symptoms of CVD in general:

1-Chest pain: First and main sign to be aware of (vip)
2-Dyspnea: shortness of breath can be associated with CVD like Left sided heart failure/Respiratory
*Left sided heart failure- the left side of the heart doesnt work properly so the blood will accumulate in
the lung and no blood will reach the heart causing dyspnea.
3-Cyanosis (bluish discoloration)- symptom that more associated with heart failure it happens in :
*Asthmatic pts.
* Pts with less blood oxygenation to CNS
* Children with Right-to-left shunting or Left-to-right shunting (ventricular blood will mix)
4-Palpitations: Arrhythmia like atrial fibrillation
5-Syncope:sudden loss of conscious due to decrease blood supply.
6-Edema of ankle: due to Right sided heart failure, the blood will still in the body and doesnt go to the
right side causing edema in peripheries.

Ischemic heart diseases(IHD)
- is the most common type of hearts disease and the cause of heart attacks.
-Caused by plaque accumulation along the inner walls of the coronary arteries causing ischemia.
-Ischemia means a reduced blood supply, so less oxygenated blood reaches the heart.
-Pt. complains of chest pain.
-Pt. with IHD will have :
*Angina pectoris
*Myocardial infarction
*Acute coronary insufficiency
Angina Pectoris
-Temporary myocardial ischemia due to CVD
-Due to Atherosclerosis ,thrombosis, or arterial spasm which cause a partial block in coronary artery.
1-Stable Angina: Pain only in exertion (effort) relieved in a few minutes by rest and sublingual
GTN(Glyceryl Tri Nitrate)
2-Unstable Angina: Angina at rest or sudden onset with rapid increase in severity.
3-Cardiac syndrome X : Clinical features of angina but normal coronary arteries on angiogram.
4-Prinzmetal angina (Vasospastic): Caused by coronary artery spasm at rest, like Unstable angina but
differs in pathophysiology.
5-Decubitus angina: Pain on laying down.

-Pt feels chest pain when climbs the stairs pt. have IHD if this frequent (every week, 10 days,1
month) then its Angina pectoris send pt. to his physician.

-Mangement: Late Morning
NOT at early morning High epinephrine Increase load on the heart.
NOT at Evening The pt will be tired.

-We can give LA comfortably in Late morning because there is less epinephrine in the blood but its
debatable because generally we dont give LA intravascular so in real dental practice its make no
-Reduce anxiety and stress
-You can use LA with or without epinephrine.
-If LA with Epinephrine (1:100,000) : in Adults not more than 4 cartilages.
-GA alright , but if recent attack wait for 3 months.
-Emergency care: GTN, Oxygen mask ,keep setting upright if pain persist- chewable Aspirin 300mg
***Epinephrine for normal people up to 0.2ml which means around 7-8 cartilages.
*For Cardiac compromised pt. up to 0.04ml.
1-GTN: dilate vessels very quick connection to the heart, easily absorbed from sublingual areamore
blood supply to myocardium.
2-Full oxygenation mask.
you can continue dental Tt. After 5 minutes if the pain subsides, if not you can suspect MI so you give pt:
3-Aspirin (Is an Antiplatlet ,It doesnt interfere with Tt. Cause the risks of stopping it more than benefits, so
you dont have to stop it before treatment).
* Some doctors demand stopping it 8 days before Tt.
Myocardial Infarction:
-Complete occlusion of one or more of coronary arteriescomplete Blood supply deficiency.
-Crushing and strangling pain at Midsternal area , long duration pain (more than 5 mins), pt may have
choking and vomiting.
2-Full Oxygen mask
3-Chewable Aspirin 300mg(Antiplatelt)
4-Morphine(Opioid)-Pain killerreduce painreduce load on the heart.
-Pt position is Upright (while pt. is awake)
-First there will be sweating, Fatigue and after a while loss of conscious->so you change the position to
If the pain doesnt subside after 2-3 minutes we call for help.

Congestive heart failure
-Inability of the heart to pump blood needed for metabolic process.
-If the affected site on
* the right- right sided heart failure
* the left- left sided heart failure.
* the heart and lung cor pulmonale- problem in both heart and pulmonary artery or the lung
*Pt. position always UPRIGHT .
*Late morning
*Use less epinephrine.
avoid putting pt. in 60 degree chair then raising itthe pt will have hypotension
1-Beta-blockers reduce blood pumping so decrease the load
2-Digoxin instead of normaly 60-1000, it pumps less.
3-Antihypertensive(Anti HTN)-> to reduce pressure and after load on the heart.
1- Digoxin interact with antibiotics like Erythromycin(second choice after Amoxicillin).
2-Digoxin and some Beta-blockers(Anti HTN) like Propranolol interact with Epinephrine.
** Mechanism of action:
Epinephrine Increase blood pressure
Beta-blockers Decrease blood pressure
if two drugs interacted lead to very raise in blood pressure so decrease using epinephrine .
-Normal blood pressure is (120-130/80-89).
-Hypertensive pt has blood pressure above (140/90).
-History taking is important to know how bad is the HTN- If pt take medications then its bad HTN.-
* LA with epinephrine(1:100,000) up to 4 cartilages (not more than 0.04mg)
*GA is alright
GA contains hypotensive agents and the pt is also taking anti-hypertensive drug so this should lower the
blood pressure a lot BUT in this case we dont stop the antihypertensive drug To avoid Rebound HTN
after surgery.
-If hypertension exceeds the limit the pt, will have a stroke.
-Myocardium can stand HTN but Brain cant(there will be hemorrhage).
-Reduce stress

-Sedation : Benzodiazepine(Valum).
-Short Treatment duration.
Rheumatic Fever
-Caused by bacteria called: Streptococcus Pyogenes (Beta-haemolytic streptococci).
-Untreated childhood sore throat caused by Strep. Pyogenes causes the body to produce antibodies against it,
this will lead to cross-antigenicity.
-Cross-antigenicity: the antibodies start attacking the bacteria and consider the heart as foreign agent.
-Pt has multiarthralgia and problems in the heart.
-Pt. should take prophylactic antibiotic to prevent Infective Endocarditis(IE)
-Always ask the pt. if he had untreated sore throat if yes refer to specialist doctor to prescribe prophylactic
antibiotic to take before the treatment.
-Reduce stress- Diazepam
-Short dental appointment.
Infective Endocarditis
-Bacterial infection leads to distortion in one of the cardiac valves.
-Caused by Streptococcus Viridans which found most commonly in oral cavity.
-Any pt has problems in cardiac valves in general should take prophylactic antibiotics before treatment to
prevent inflammation of the valves.
- if the patient had problem in one of valve like:
*mitral valve stenosis
*prosthetic valve
* pulmonary valve stenosis
*rheumatic heart valve
*Previous infective endocarditis
*Complex cyanotic congenital heart disease
and the pt didnt take prophylactic antibiotic he will develop:
*Low grade fever.
* Arthralgia (pain in joint)
*Cardiac problems: arrhythmia and pain- due to the bacteria that entered from oral cavity and settled in the
valve and led to inflammation of the valve and total distortion to the area.
-Pt with IE should enter hospital and take Antibiotics for 2 weeks, in some severe cases pt will need prosthetic

heart valve.
-Greater percentage will die from IE.
-Mangment : prophylactic antibiotic
Always ask if the pt has allergy to penicillin:
If pt dont have allergy ADULT : 4 tablets of Amoxicillin (500mg) 2g of amoxicillin
Or we can give Ampicillin as liquid but Amoxicillin is better.
CHILD: 50mg/kg of Amoxicillin(tablets) or liquid.
Make pt return after hour to make sure that antibiotics in the blood is highest.
If pt has allergy Clindamycin, Azithromycin(microlide), Cefazolin
same thing for children but less dose (Azithromycin 16mg/kg,Clindamycin 20mg/kg),

Respiratory Disease
-Clinical features:
*Finger clubbing( sign you can see in Respiratory, Liver and Cardiovascular disease)
-The difference between signs and symptoms:
Signs: Something doctor see
Symptoms: Something Pt. tells you about.
-GA is contraindicated.
-GA for Pt with influenza-wait until recovery
-GA for pt. with Asthma give cautiously .
-Same thing applied to Analgesics(Pain killers), Narcotic (Heroine and Morphine), these drugs lead to
respiratory depression.
-Caused by : bronchospasm and Hyper-irritability .
-Expiratory wheezing (inspiration us active and expiration is passive)
-Less Oxygen saturation(instead 95% it will be 90%)
-Difficulty in breathing.

-Due to 2 factors:
1-Externsic Factor- happen in spring due to air aerosols , the body will form IgE that stimulate mast cell to
release histamine.
2-Internsic Factor- Unstable Mast cells, so for any reason mast cells degranulate and release histamine so
lead to asthma.
1-Corticosteroids- Cortisone
2-Beta-agonists- Salbutamol
*Corticosteroids tablets or Fenoterol(but it has many drug-drug interaction)
* Refer if they need medical consultation.
*Reduce stress and anxiety.
*LA can cause asthma, dont give more than needed.
*During GA pt is conscious because bronchiole will be spasm.
*GA Put tube itself , treat cautiously cause pts can get easily lung infections, pneumonia.
-Emergency care:
* 4-6 pushes from inhaler.
*Cortisone (because asthma is sort of hypersensitivity)
Liver disorders
-Liver is important in drug metabolism, any problem occurs , impaired drug detoxification occurs leading to
drug toxicity.
-Liver responsible for production of coagulation factors(by means vitamin K), any problem will lead to
Liver Cirrhosis
-Major disease affects liver caused by:
*Liver is reservoir of Viral infections like Hepatitis A, B , C ,D, which leads to cirrhosis.
*Alcohol consumption( >21 units a week for males, 14 for females)-> here liver is fibrous tissue not an active
-If pt. has Jaundice , Cirrhosis or Hepatitis referral and consultation about his situation is needed.

-Many drugs should be avoided/CONTRAINDICATED:
1-Paracetamol- instead we give NSAIDS (because Paracetamol metabolized in liver and NSAIDS in kidneys)
or we can reduce the dose under proper consultation from physician.
2-LA from Amide group like: Lidocaine, Mepvacaine.
3-Valuim (Benzodiazepine like Lorazepam and Diazepam)
4-Antibiotics like Penicillin
*Pt. needs comprehensive treatment.
*Full blood test-Bleeding profile: INR, PT,PTTProlonged in liver diseased pts.
*Liver function test- usually is high
*They have bleeding tendency use IV vitamin K. as a main drug for such patients.
- two types: active and chronic, active is when pt have virus in all body fluids so they are very infectious.
-Hepatitis B and C are the types that we worry about.
-Dentist should have Hepatitis B Vaccination, there is only Vaccine for Hepatitis B.
-We dont have Vaccine for Hepatitic C and HIV ,they considered more fatal.
-Hepatitis C- fatality of 50% others have risk to develop Hepatocelullar carcinoma)
-Hepatitis B easiest virus to be transmitted by needle stick injury > Hepatits C>HIV
Renal failure
-Renal Failure patients are immunocomprmised so they need antibiotic prophylaxis .

-If they are having hemodialysis, then they are taking anticoagulants, and this will limit and might prevent you from treating

- Best day to treat such patients is the day after hemodialysis because the blood will be in its best performance it is
fresh and new, and the blood is free of heparin (the blood lost its bleeding tendency).

-Antibiotics before and after treatment is required for these patients.

-They are prone to have anemia because they have deficient erythropoietin which is normally produced from the kidneys
We should check if those patients have any sort of viral diseases, as they are prone to catch a disease from the hemodialysis
machines .

Endocrine disorders
Diabetes Mellitus
-Diabetes mellitus is a disorder caused by an absolute or relative lack of insulin
-there can be a low output of insulin from the pancreas or the peripheral
-Persistent elevation of blood glucose level.
-Normal fasting blood glucose is 100 mg/dl, anything above that is not normal even if it is an elevation of 20
-Glucose tolerance test is a good test to determine if a patient is diabetic ,we first check the fasting blood
glucose, and then we give him glucose and we recheck blood glucose after two hours, if it is below 11.1
mmol/liter then this patient is not diabetic, if it is above he is definitely diabetic.
-Fasting plasma glucose (measured before the OGTT begins) should be below 6.1 mmol/L (110 mg/dL).
Fasting levels between 6.1 and 7.0 mmol/L (110 and125 mg/dL) are borderline, and fasting levels repeatedly
at or above 7.0 mmol/L (126 mg/dL) are diagnostic of diabetes.
***Diabetes mellitus is a disorder caused by an absolute or relative lack of insulin: there can be a low
output of insulin from the pancreas or the peripheral tissues may resist insulin.

it is Absolute when the patient has diabetes type 1, they have autoantibodies against the B- cells of
Langerhans, occurs in young people, they have deficient insulin, they sustain this disease early, it is
insulin dependent from the beginning, no benefit from giving oral hypoglycemic drugs, they need insulin
injection .This type is genetically determined (doesnt mean it is inherented, because it is an
autoantibody) .

Type 2 which is non insulin dependent (there is enough insulin in their bodies), but they have resistance
to the receptors of insulin (they wont let glucose get in) and it is inherent.

Gestational diabetes: happens in pregnant females usually in their third trimester, they usually recover
after delivery but such females are very susceptible to have diabetes in the future.

P.S infants of diabetic mothers are born overweight because there is too much sugar in blood and sugar
can cross the placenta without hormones, so the baby will get bigger .
Oral manifestation of diabetes mellitus
1-high level of alveolar bone resorption
3-delayed or defective wound healing
5-pulpitis in non carious teeth
6- impaired sensation in tongue
7-Acetone smell (ketoacidosis): hyperglycemia-body will degrade fat (triglycerides) and supply the
organs with some other nutrient---> waste products of such process are ketone bodies. Patients who reach
this level are very poorly controlled.

Of course this happens in non controlled diabetic patients, controlled diabetic patients can be treated as
normal people.

Dental management:
*diabetic patients are given early morning appointments, we want them to come after theyve had their
breakfast and medicine, and most importantly not to miss a meal.
*Regarding premedication some would advise certain antibiotics as prophylaxis if the patient come as an
*Make sure appointments are short (about 30 min).

-difference between anemia and bleeding disorders has to be very distinct.
-Bleeding disorders : inclination of the patient to have bleeding from a small cut
-Anemia :can be defined as either of the following:-
1-Decrease in number of circulating RBCs.
2-Hemoglobin level below normal (the most important indication).
* for adult females below 11.5 g/dl.
* For adult males below 13.5 g/dl
* children(below 11 y/o) below 11 g/dl
3-Haematocrit (amount of cells in plasma) below normal range.

-To indicate different types of anemia we can use MCV (mean corpuscular volume) which gives us an
idea about the size of the RBC.
MCV Patient hematocrit / RBCs count= normally 79-98Fl.
So we have :
1-Macrocytic anemia : > 98 fl.
2-Microcytic anemia: < 79 fl (most common type "Iron deficiency anemia")
3- Normocytic anemia: 79-98 fl

-Hemoglobin level and MCV are important to classify patients as anemic

General Clinical features of anemia (symptoms):
Chronic fatigue *
*fainting.(not specific)
*Breathlessness (very important indication)
*Angina pectoris.(chronic anemia can cause Ischemic heart disease)
* Ankle edema
*Intermittent claudication (pain in the muscles of the leg upon walking)

Nonspecific Signs of anemia:
1. Pallor but not jaundice.
* Jaundice is a yellowish pigmentation of the skin
*Pallor is reduced amount of oxy hemoglobin in skin or mucous membrane, a pale color which can be
caused by illness, emotional shock or stress, stimulant use, or anemia.
2. Tachycardia- more than 100 beat /min ( NORM 60-100 beat /min), it is something you can hear
3. palpitation
4. Full pulse- its something you can count.
5. systolic flow murmur
6. congestive cardiac failure due to lower oxygen-carrying capacity of blood that leads to ankle edema.
-Heart is normal but blood is abnormal
7.rarely they develop papilledema and retinal hemorrhage in an acute bleeding .

Specific signs for severe anemia:
1. Koilonychias: spoon-shaped nails, usually we see it in iron deficiency anemia.
2. Jaundice may be in some types of anemia mainly hemolytic anemia(destructed RBCs will increase
the bilirubin level which leads to jaundice)
3. Bone deformities; mainly in thalassemia major and sickle cell anemia.
4. leg ulcers: mainly in sickle cell anemia

Classification of anemia
Types of anemia Examples


(MCV is low <79 fl)
1-Iron deficiency.
(most common

-RBCs on the blood film are small .
-low Iron content
-high iron binding capacity to
compensate the deficiency.

Hypochromic -RBCs are pallor
than normal (low redness) -
Microcytic - small average RBC

2-Thalassemia.( pseudo plastic anemia)
-inherited autosomal recessive blood
disorders caused by the weakening and
destruction of red blood cells
-Small RBCs
-Low MCV
-Normal iron content-the patient source
of consumption and absorption of iron is
normal but the problem in the RBCs

Microcytic Anemia
Two types:
1-Iron deficiency anemia

Iron deficiency anemia (MOST COMMON): - 1
-Microcytic, Small size RBC in blood films
-MCV below <79 fl.
Low Iron content
-This type of anemia requires:
* good diet it gives us around (15-20 mg)of iron
-from vegetables around 1-10% and 10-20% from animal foods
-Iron absorption occurs in duodenum and jejunum so any patient has diseases in duodenum and jejunum
will be anemic.
*Ferrous form of iron is better in absorption than ferric form.
*Gastric acid is needed for the adequate conversion of iron salts from ferric to ferrous forms for their
absorption from the proximal small intestine.
- people who take anti-acids to neutralize their low acidity has less iron absorption
Causes of iron deficiency:
1.Poor iron intake (the most common cause in males)
2.Pregnancy which requires an increased demand of iron (pregnant ladies must take supplements)
4.Chronic blood loss from:
Vitamin B12 deficiency
Malabsorption (Post-gastrectomy)
Foliate deficiency ,
Aplastic anemia,
Liver diseases,
Hyperchromic-very reddish color
of RBCs-
Macrocytic-large average RBC
size>99 fl



Normal MCV
Chronic diseases.

Renal failure.
Normochromic-normal color of
Normocytic-normal average RBC

-Peptic ulcer(most common cause),malignancy in the intestine , patients with esophageal varices due to
portal hypertension have a strong tendency to develop bleeding.
-Menorrhagia or Hematomunia is an abnormally heavy and prolonged menstrual period at regular
5. Achlorhydria: production of gastric acid in the stomach is absent or low.
6.GI disease
7.Dietary factors:
*low iron
*low vitamin C
*High coffee and tea intake( Neutralize gastric acidity)
8.Demographic factor:
9.Socioeconomic factor
*Alcohol abuse
*Poor attention

Clinical features of iron deficiency anemia:
1. Brittle nail (koilonychias)- thin and bent
2. Angular stomatitis: is fungal infection sometimes it can be bacterial infection leads to crusting over the
angle of the mouth , it is more common in some anemias than others.
3. Brittle hair
4. Atrophy of tongue papilla (red and smooth tongue burning tongue)
5. Glossitis (reddish and depapillated tongue accompanied with pain)

PlummerVinson syndrome (PVS), also called PatersonBrownKelly syndrome presents as : Triad
of : dysphagia, glossitis, and iron deficiency anemia
It most usually occurs in postmenopausal women.-
-This patients are very prone to SCC(squamous cell carcinoma).
-Some claim that if iron deficiency anemia in this syndrome declined you might save this patient from the
6. parotid gland enlargement
7. Splenomegaly
8. Failure to grow.

Investigation for iron deficiency anemia:
1. If Hemoglobin level is <10 then need to test MCV, as we mentioned should be <79 fl.
2. Iron binding capacity is very high in iron deficiency anemia, due to low iron content.
3. Send Blood film to pathologist , you will see
a. Poikilocytosis: variation in shape of blood cells. b. Anisocytosis: variation in size of blood cells.
4. Endoscopy for GI bleeding


MCV <79 FL-
-Iron level is normal
-It is an Inherited autosomal recessive blood disorders.
-Disease is caused by the excessive destruction or degradation of red blood cells due to formation of
abnormal hemoglobin molecules, because of a defect through a genetic mutation.
There are TWO major forms of the disease :
1- Thalassemia : defect in globin chains
2- Thalassemia : defect in globin chains (more common in our region).
-The body cannot produce one of the globin chain because of a defect through a genetic mutation.
This will lead to over production of the second globin chain (for ex: impaired production of alpha globin
chains, leading to a relative excess of beta globin chains), so an abnormal hemoglobin molecule.So
excessive destruction or degradation of red blood cells at the end of the day.

Thalassemia divided to :
1. Major thalassemia ( Cooley's anemia )
2. Minor thalassemia (very common); carrier patient without symptoms.
-If mother and father have traits ( carriersminor thalassemia ) then the kids:
*25% major thalassemia
*25% normal kids
*50% minor thalassemia

Symptoms of major thalassemia :
1. failure to Thrive
2. Intermittent infection: can easily attract infection.
3. Severe anemia ( hemoglobin is 6 or 7) which lead to Extramedullary Hematopoiesis -
overproduction of defected blood from unusual sites, like:
*Bone marrow.
*Bone of extremities
*Liver- it will lead to Hepatomegaly
*Spleen- it will lead to Spleenomegaly
* Mandible/Maxilla- in Maxilla it leads to chipmunk face.
-Bone of the skull enlarges because of blood production, it actually gets thinner and empty from inside
where it produces blood.

-Inside this empty space there is a functioning area that appears like collection of hair connecting the
outer plate and inner plate of the skull and it contains living cells that produce nonfunctioning blood.
-Thalassemic pt. will have a lot of blood borne viruses/infections due to frequent blood transfution(2-4
times a year).
-LA is safe in general.
-Sedation, its ok BUT- Thalassemic pt. has low functioning blood-> low blood oxygenation->he will not
stand procedure's stress->so Full(100%) Oxygen mask should be supplied, to make sure that the
functioning blood is saturated with Oxygen.
-GA is hard in some pts. with enlarged maxilla, its difficult to introduce tube inside airway.
- Enlarged Maxilla appears empty from inside due to rarefaction (due to extramedullary hematopoisis).

Macrocytic anemia.
1-Vitamin B12 Deficiency
2- Folic acid deficiency

Vitamin B12 Deficiency
-Vitamin B12 and folic acid deficiencies are part of the Macrocytic Anaemia (high MCV; above 98).
- Intrinsic factor normally binds to vitamin B12 and carries it to somewhere in the intestine, so it ease the
absorption of the vitamin in the intestine; in the ileum,
-if the patient has problem with the intrinsic factor the vitamin will not be easily absorbed from that area.
- Most common type of macrocytic anaemia, it is either:
1-Autoimmune disease (we call it Pernicious Anaemia)
2-due to nutritional problems.(common).

Autoimmune disease( Pernicious Anemia):*
-Is the presence of auto antibodies against the intrinsic factors of the parietal cells, or against the parietal
cells itself that produce the intrinsic factors! In both ways we won't have intrinsic factor, so there is less
Vitamin B 12 absorption.
- Pts. ith Pernicious anemia will have :
*autoimmune diseases like the Thyroid disease, Addison's disease.
* higher incidence of gastric carcinoma.
Causes of vitamin B12 deficiency:
1-Insufficient dietary intake (vegan/vegetarian)
*main source of the vitamin is red meat.
2-Impaired absorption due to:
* problem in stomach so no production of intrinsic factors.
*will be small bowel or celiac and chron's disease ( it is an inflammatory bowel disease), tropical sprauce
* bacterial overgrowth in the ileum; where the vitamin is mainly absorbed, or

*ileac disease
*patient simply has had a surgery.
3-Chronic pancreas diseases for example Zollinger-Ellison syndrome.
4-Nitrous Oxide this is theoretical, because of a test that was made in vitro not in vivo, and they found
that the nitrous oxide inactivates vitamin B12.
5-Neurological syndromes:
*Peripheral neuropathy: patients with vitamin B12 deficiency sometimes complain from symmetrical
parasthesia in their fingers and toes.
*Regressive weakness and ataxia: patients cannot move well, but this happens in sever vitamin b12
deficiency cases.
*Syndrome Paraplagia
6- Mental changes: the patient can develop psychosis, dementia
7-Digestive syndromes: glossitis (red sore tongue), angular stomatitis. These are very uncommon here,
they are more common in iron deficiency.
8- Hepato-spleenomegaly .
9- Gastric atrophy and achlorohydria: the parietal cells produce many things including intrinsic factor and
HCl. The b12 deficiency patient doesn't have HCl in their stomach so it loses its acidity
Dental aspects:
-Nitrous oxide sedation -- we'll talk about this theoretically as the experiments were made in vitro", it
worsens the problem. So we try to avoid using it in this case.
- Aphtus ulcers
Folic Acid Deficiency:
Here the body doesn't have stores for folic acid, this means "the body gets his needs of the acid from the
food u eat in the day; to produce blood cells, but the day in which u don't eat food with folic acid u won't
have folic acid for that day.
folic acid is absorbed in the proximal small intestine "in the duodenum just like the iron".
-Pregnancy : pregnant ladies take supplements, but the thing that they really have to take is folic acid,
otherwise they will have higher rates of neural tube defects that leads to cleft lip and palate .
Dental aspects:
-Just like b12 deficiency; but the angular stomatitis : it's more common here than in b12 deficiency.

Normocytic Anemia
Normal cells shape, normal cells number, less Hb content.
1-Anemia of chronic disease.
Aplastic Anemia
Aplasia of bone marrow with peripheral blood pan-cytopenia.
- bone marrow; that produces all the types of blood cells, becomes destroyed due to autoimmune diseases,
medications or due to cancer so the patient has aplasia"no cells in the blood, only the white plasma".
-this disease can be reversed if the bone marrow goes back to its normal state and starts to produce blood
-Pts have low blood pressure and bleeding tendency due to the absence of blood cells

Causes of Aplastic Anemia:
1-Congenital ( fanconi anaemia) it was found commonly between the people that marry their relatives,
and it's still seen now.
2- Acquired due to:
*ionizing radiation
* radiotherapy (lymphoma)
* insecticide (farmers)
3-Infections : measles
-Salacious infections : tuberculosis. 4
Clinical features:
1-Blood anaemia
Bleeding tendency - 2
3-Infections: No WBCs so they can develop any sort of infection including fungal infections

Anemia of chronic disease:
Sickle Cell Anemia (Normocytic Anemia) Hemolytic Anemia:
**Thalasemia is called hemolytic anemia, but Thalasemia is microcytic anemia, here we're talking
about normocytic anemia.
-Red cells usually survive for 120 days, but in hemolysis the RBC lives just for a short period of time then
it gets lysed. This leads to anaemia and for one of the symptoms that we talked about before "Jaundice"
Causes of Sickle Cell Anemia :
-We ask the patients with glucose 6 phosphate not to take certain medications and they can live a normal
life! these medications are:
*NSAID :Aspirin, Prufin
* Some Antibiotic.
-We usually give aspirin as an antiplatelet.
- Prufin as it's a very good dental analgesic. BUT its CONTRANDICATED in Pts having glucose 6
phosphate deficiency
-Inherited :
* RBC membrane defects; spherocytosis,
*hereditary elepto or hemoglobin abnormality (not abnormality in the cell shape, but in the hemoglobin)
- Thalasemia, Iron Deficiency Anaemia and Sickle Cell Anemia and metabolic defects such as Glucose
Six Phosphate Deficiency : Glucose 6 Phosphate Dehydrogenase enzyme will be defected.

- The patient will have substitution in Glubin Chains(amino acids chains) " and chains" any
substitution or change in any amino acid will lead to sickle cell anaemia.

Sickle cell anaemia has 2 types:
1- Sickle cell major: homozygous, very severe.
2- Sickle cell trait: heterozygous, patients have normal life, but at some point they might develop sickle
cell disease.
Clinical features:
1-Painful crisis:
- In sickle cell patient, It is always there.
- In the sickle cell trait, they develop painful crisis too.
-sickle RBC gets destroyed because it's not functioning, and the destroyed cells will accumulate in the
area where they were destroyed, if they were destroyed in the bone the patient will feel pain in that area
because the vessels are closed, the patient will have infarction (very painful). And if they were destroyed
in the heart it will lead to MI (fatal). or in the jaws. Or in the liver, spleen or lung, and so on. The main
problem about the infarction is the pain!
2-Hematological crisis
-In heterozygous "the trait", the Para-virus for example will lead to hematological disorders SCA.
3-Chronic anaemia.
4-Hyperbilirubinemia; increase bilirubin production; when the blood cell are destroyed, it will produce
bilirubin, part of this bilirubin will go to:
* GIT, and the body reabsorb small part of it
* but when the produced bilirubin amount is very high, it will go to the blood causing jaundice
*Causing also higher rate of stones formation in the gallbladder
-In the liver where the destruction process occur and bilirubin is produced!
5-Infection: the MAIN cause of death!!! They can easily get infected.
6-Sequestration syndrome; blood accumulation.

Dental aspects:
In heterozygous:
1-Do careful investigations like electrophoresis, this will gives us accurate results and diagnosis (positive
diagnosis) .
2-Full Oxygenation: the patient has normal life, but he might develop SCA under stressful situations that
need high oxygenation; infection, starvation, or any low oxygenation cases (like traveling by planes), or
dental treatment these are situations where the patient can develop crisis or SCA.
3-Local anesthesia: is fine but they say don't use the one with Prilocaine, coz it causes
4- Avoid NSAIDs.
5-Prophylactic antibiotics: because they're prone to have infections, that might cause crisis!

Orofacial manifestations:
1-The patient may come to your clinic complaining from pain in his teeth but you examine him and
see nothing, and no pain around the teeth. So simply the cause is infarction! That might lead to
osteomyelitis "infection in the bone" if more infracted sells accumulate.
3-Skeletal, not dental development is delayed
4-Steroids: cortisone
-under stress, patients will have adrenal insufficiency. So they need to take supplements if they are going
to do something stressful.
We have these examples:
A patient who had taken steroids a year ago or less; we ask the patient to come in the early morning and
ask him to take steroids "same amount of steroids",
- we sometimes give them IV hydrocortisone (25 -50 mg). As a cover! And others said we should give
the patient a "post-operation" hydrocortisone (25 50 mg) (for 1 3 hours).
-Or a patient who had taken the steroids more than 1 year (we treat them normally)
-A patient who is taking steroids now, here we don't only care about the steroids intake we care more
about the cause or the disease that caused the patient to take steroids like : Liver and lung transplant!
Or Behet's disease.
- we need to know that any patient with Behet's disease is taking steroids
- Definition: simply means to stop any bleeding.
- The haemostasis always comes in three steps: primary, secondary &tertiary.
- Assume that there is an injury, how the body will react to stop bleeding?
1. Primary haemostasis:
- Firstly, primary haemostasis by vasoconstriction.
- Secondly, platelets accumulation at the site of injury.
- The platelets release different transmitters: ADP, thromboxane A2 & prostaglandin E2.
2. Secondary haemostasis:
- The platelets will give signals to clotting factors.
- The clotting factors need to bring about the proper amount of fibrin blood.
- The clotting factors pass through cascades, either extrinsic or intrinsic which depends on the trigger.
- The extrinsic and intrinsic pathway differs at the beginning by thetriggering factors, and then they will
become a common pathway.
- The common pathway include factors V & X (5, 10).
3. Tertiary haemostasis:
- Defined as fibrinolysis to the clots.

-After a month (for example) you will see that the injury has healed all together-tertiary haemostasis.
-When a patient comes to you for extraction, RCT or whatever, first of all you will take history.
-For hemorrhagic diseases (bleeding disorders) history comes first because sometimes bleeding tendency
cant be revealed with all blood tests.
-So history is the primary way to know if there is any bleeding tendency.
*In the history examination you will be asking the patient about different systems in the body including
How would you inquire about any history of bleeding?
-Ask the patient about any previous disorders.
- Have you ever get hospitalized because of bleeding that resulted from accident?
- Have you ever had a long period bleeding after tooth extraction? (Normally, it stops after 24 hours).
- Patient with a previous surgery and no bleeding disorders have occurred means that we are most
probably not worried and the patient is fine.

Extra notes (from the book):
- There could be a bleeding tendency if the bleeding is unexplained by the degree of trauma or there is a
previous, or family, history of excessive bleeding such as:
- A previous diagnosis of a bleeding tendency.
- Bleeding for more than 36 h or restarting more than 36 h after operation (however, this could indicate
an infection).
- Admission to hospital to arrest bleeding.
- Blood transfusion for bleeding.
- Spontaneous bleeding.
- Convincing family history of one of the above combined with a degree of personal history
- Treatment with significant drugs such as anticoagulants.
Blood tests
1. Tests-bleeding related to platelets:
** Platelet count: In the primary haemostasis, if there is no vasoconstriction or there are no platelets, the
test we apply is platelet count.
- Normal number of platelets is: 150-400 X 10^9/L.
Extra notes (from the book):
- The platelet count provides a quantitative evaluation of platelet function.
- A platelet count of <150000 can be associated with major post- operative bleeding.
** Bleeding time:
- The normal bleeding time is: 2-9 min. the problem with bleeding time that it has a wide range (2-9 min)
so that an argument says that bleeding time is not very specific.
- Bleeding time is a test used to examine platelet function.
- Bleeding time is affected by: platelets count, platelets function & blood vessels.
Extra notes (from the book):
- The test measures how long it takes a standardized skin incision to stop bleeding by the formation of a
temporary haemostatic plug.

- The bleeding time is prolonged in patients with platelet abnormalities or taking medications that affect
platelet function.
** Blood film:
This test is used with CBC(complete blood count) test. It is not used for bleeding disorders but it is used
for patients where we suspect malignant blood diseases (leukemias).
- Leukemias in general tend to have bleeding problems.
2. Tests-coagulation:
Case: A patient who hasnt a problem in the primary haemostasis but he has a clotting factor problem
resulted from a liver disorder as he taking medications like warfarin or heparin. So the patient is taking
medications to make the blood thin.
-For this patient we examine the coagulation.
- Coagulation is more serious than bleeding related to platelets because it is a long lasting problem and
no stabilization will occur without a proper fibrin plug.
- Tests used to detect coagulation: APTT, PT & INR.
*Activated partial thromboplastin time (APTT):
- Purpose: measures the intrinsic pathway (factors: XII, XI, IX, VIII).
- Normal time: 25 sec.
Extra notes (from the book):
- APTT measures the effectiveness of the intrinsic pathway to mediate fibrin clot formation.
- APTT is most often used by physicians to monitor heparin therapy.
* Prothrombin time (PT) :
- Purpose: measures the extrinsic pathway (factor VII).
- Normal time: 11-15 sec.
Extra notes (from the book):
- PT measures the effectiveness of the extrinsic pathway to mediate fibrin clot formation.
- A normal prothrombin time indicates normal levels of factor VII.
- PT is most often used by physicians to monitor oral anticoagulant therapy such as warfarin
* International normalized ratio (INR):
- The INR is very good source of indication for bleeding tendency especially for patients taking warfarin.
- INR= (PT of patient) / (PT of normal people).
Extra notes (from the book):
- Normal INR= 1.
- An INR above 1 indicates that clotting will take longer time than normal.
3. Tests-others:
1- Fibrinogen.
-Fibrinogen degradation products (FDP) - especially D-dimers.
- Patients with hypercoagulopathy will have other problems as DVT (deep venous thrombosis) - for
those patients D-dimers test is used.

2- Specific factor assays.
- Assume that you have a patient with haemophilia, how would you examine haemophilia? By APTT.

How would you determine which factor is needed (in terms of factor amount and severity of the disease)?
By specific factor assays.

3-Tests of physiological inhibitors (anti-thrombin, protein S, protein C, hereditary resistance to activated
protein C-APC).
- Patients with high level protein S & protein C have a chance of excessive clotting disorders
(hypercoagulopathy), for that a tests as anti-thrombin is needed.
Vascular defects
Vascular defect means that the patient has a defect in the vessels so that part of the primary haemostasis
will have a defect.
-Such cases of vascular defects are usually hereditary.

Hereditary haemorrhagic telangiectasia (Osler-Weber-Rendu syndrome):
- Vascular defect: the vessels are thin.
- Autosomal dominant.
- Telangiectasia on skin & mucosa: the patient will have very fine and superficial vessels over the face.
- Recurrent bleeding from fragile vessels: one of the most fragile vessels in the body is the nasal vessels,
so that the patient can bleed from the nose easily.
- Iron deficiency anemia: related to chronic bleeding.
- Treatment:
1 . Cryosyrgery: is a treatment with ice.

It is placed on the vessel (when it is superficial) and it will lead to necrosis as a result of the very low
temperature so that ice crystals forms inside the cells stopping the bleeding from the vessels.
2. argon laser.
- Dental aspect:
1. Bleeding from minor trauma.
2. Regional LA should be avoided.
3.General anesthetic as well should be avoided.
Notes: 1. you should be very conscious about using regional LA for Patients
with bleeding tendencies in general. Remember: regional means Block. So that when you perform a
regional LA you will go through many layers which will lead to too many traumas, As a consequence
bleeding will occur. A
substitute for regional LA will be? Infiltration.
Notes: 2. a patient with bleeding tendencies (vascular defect) will have a
surgery under GA and a tube passing through the nose, is there going to be any problem? Yes, as we said
for those patients with vascular defects, platelet problems or coagulation problems, the tube passing
through the nose or the mouth will traumatize the mucosa and any source of trauma
will lead to bleeding.

Platelets disorders
1- Reduced production: cancer patients or patients with bone marrow diseases have reduced production
with all blood cells.
2- Any disorder in the bone marrow that can kill all types of cells or either one type can predominate.
* Leukemia: in some patients with leukemia you will find very high white blood cells while other sorts
of blood cells are depressed.
*Aplastic anemia: the patient will have a defect in anything related to the bone marrow.
* Medications: Like chloramphinicol can lead to reduce production which
will lead to platelet disorder as a part of many disorders-consequentially the patient will have bleeding
* Sequestration hypersplenism: the platelets destination is the spleen.
- There are some patients whose treatment is by splenectomy (removal of spleen). Why is that? Because
when the patient has hypersplenism, the spleen will have high ability of sequestration and the body will
not be able to cover the huge number of platelets.
3- Increased destruction: a well known disease for increased destruction is :
**ITP- which stand for Idiopathic Thrombocytopenic Purpura that can be acute or chronic.
- Purpura: A small superficial bleeding.
- Intra-orally: it is called petechia.
-Around the eye: it is called: Ecchymoses.
** Certain drugs: as we talked about chloramphinicol (in some patients) that can lead to over anti-bodies
and can lead to Aplastic anemia destroying all cells including the platelets.
** HIV: the HIV can cause an ITP-like disease as HIV thrombocytopenic purpura.
**Aspirin is the prime antibiotic medication worldwide, For a patient taking aspirin, we expect to have
deficient platelets for 1 week.
- Aspirin shouldnt be stopped. Deficient platelets for 1 week rarely cause significant post-operative
haemorrhage, stopping Aspirin can lead to other problems, Aspirin shouldnt be stopped.
- Tests for Aspirin: Bleeding time (2-9 min) & platelet count.
If the platelet count is normal but the bleeding time is not, means that there is a problem in the platelet

Hess test: not used widely.
- How it is performed? Pressure is applied to the forearm with a blood pressure cuff.
- When the pressure is applied for Patient with platelet disorders, they will have purpra all around the
extension meaning that this patient is having bleeding disorders.
- Extra note: this test is neither sensitive nor specific.
* Thrombocytopenia:
- Platelets count below 100X10^9/L.
- A patient with thrombocytopenia has a defect in primary haemostasis so that there will be petechiae and
post-operative bleeding which is superficial in its majority.

** ITP (Idiopathic thrombocytopenic purpra): it is the most common and it is an auto-immune
disease caused by auto-antibodies (antibodies against the platelets) as well as Antigen platelet membrane
glycoprotein complexes that make the body to recognize the platelets as foreign bodies.
1 . Anti-platelet antibodies.
2. Antigen-platelet membrane glycoprotein.
3. The doctor was showing a picture about ITP, since there is no slides this picture may help you:
- Megakaryocytes: are a bone marrow cells (stem cells) responsible for the production of platelets.
- The body reaction for losing the platelets will be the production of immature platelets.
-For ITP (Idiopathic thrombocytopenic purpra) patients:
1. Prolonged bleeding time.
2. PT & PTT are normal.
3. As we said earlier that petechiae could occur on skin it can also be on the palate

Dental aspect:
- Regional LA (block injections) can be given if the platelet levels are above 30X10^9/L.
- Minor surgery: if the platelet levels are above 50X10^9/L.
- Major surgery: if the platelet levels are above 75X10^9/L.
ITP treatment by:
1. Corticosteroids or other immunosuppressives are the main treatment.
2. Splenectomy is sometimes needed.

- Splenectomy predispose to infections.
-Post-splenectomy infection involving oral streptococci is rare and antimicrobial prophylaxis
(antibiotics) is not therefore generally recommended before dental procedure.
- Yet, any patient with bleeding disorder it is prudent to give antibiotics whenever you suspect of
secondary infection as the fact that secondary infection will lead to prolonged bleeding.
-ITP: is one of the most common causes of thrombocytopenia. An auto-immune disease and can lead to
Purpra and prolonged bleeding.
- Clinical features: include Petechiae,ecchymoses and post-operative bleeding.
-Management: Platelet count is indicated.
-Corticosteroids or other imm.suppressive are indicated as well as splenectomy is sometimes needed

Coagulation Defects
1. Haemophilia A.
- X-linked recessive: Affect males.
- Male-Xy: which means if the X chromosome is affected the patient is affected.
-Female-XX: which means if one of the X chromosome is affected the patient is a carrier.
- That means haemophilia A is an exclusive male disease.
- Deficient factor VIII:
We said earlier that in vascular & platelet defects there is a superficial bleeding (as it related to the
primary haemostasis), while in haemophilia there is a deep bleeding. bleeding into muscles and joints

- Bleeding from extraction sockets may continue for days or
**Severity of bleeding: depends on:
1. Severity of trauma 2. Level of factor VIII activity.
- The following table talks about the severity of haemophilia
depending on % of factor VIII:
* Very mild haemophilia: patient can generally lead to a normal
life and may remain undiagnosed but there can be prolonged
bleeding after traumaor surgery. Some may not bleed excessively
even after a simple dental extraction so that the absence of post-extraction haemorrahge cannot reliably
be used to exclude haemophilia.
* Severe haemophilia: spontaneous bleeding and prolonged bleeding from minor trauma.

- History and clinical picture.
- Increased APTT and reduced factor VIII level.
- Normal PT & INR.
- Normal bleeding time.

- Replacement with cryoprecipitate.
- Cryoprecipitate: a collection of all clotting factors.
- Other replacements: human factor concentrates or human freeze-dried factor VIII.

Dental aspect:
- Preventive dental care.
- All surgical procedures should be done in one visit following factor VIII replacement and with
minimal trauma.
- Regional LA (block) is contraindicated, if the Factor VIII level was below 30%.
- Simple extraction needs factor VIII replacement to a level of 50-75%.
- Major surgery needs factor VIII replacement to a level of 100%.
- For such patient who needs multiple extractions, the procedure is done in the hospital: referring to the
hematologist to give the patient the adequate level of factor VIII and performing the procedure in the
same day of factor VIII replacement so that you can take care of the patient pre-operatively, during
treatment and post-operatively.
- Post-operative management:
Tranexamic acid: it is either a mouthwash used 4 times daily for 10 days after the procedure or as a
tablets (1g) used also 4 times daily for 10 will reduce blood loss after surgery in patients with
2. Haemophilia B
- It is called also Christmas disease.
- Factor IX deficiency.
- X-linked recessive.
- Much less common than haemophilia A (about 1:10).

- Patient with haemophilia B needs the same management as haemophilia A except the replacement as
in haeomophila B the patient needs Factor IX replacement therapy
- Factor IX is more stable than Factor VIII, as factor VIII triggers sequestration rapidly.
- Factor VIII replacement is with 12 h half-life.
- Factor IX replacement is with 18 h half life.
- As a result Factor IX replacement gives more time for the operator to treat the patient.

- indistinguishable from haemophilia A with similar lab findings:
- Normal PT and INR.
- Normal bleeding time.
- Prolonged APTT.
-The only difference is in the factor assay: that for haemophilia B- reduced factor IX level while for
haemophilia A-reduced factor VIII level.

Von willebrand disease.
-Von willebrand is considered a common disease for: Vascular, platelet &coagulation defects.
- Deficient Willebrand Factor.
- The function of Willebrand factor is to connect between vessels, platelets and the first factor in the
clotting cascade.
-Deficient willebrand factor will lead to a bleeding problem.
-The most common inherited disease. (1% of the population).
-100 times more common than haemophilia A.
Note that:
- For Von Willebrand disease we say Bleeding disorder.
- While for Heamophilia A we say Coagulating disorder.
- Still coagulating is a bleeding disorder but Bleeding disorder will be comprehensive for Von
willebrand disease as the fact of its vascular, platelet & coagulation defects.
-Autosomal dominant: affecting both males & females.
Signs & symptoms:
1. Excessive bruising at unusual sites, mucous membrane bleeding and heavy nosebleed.
2. Prolonged PT.
3. The PTT can be prolonged or normal.
Anticoagulant therapy
- Warfarin is widely used. (Examples: open heart surgery, prosthetic heart valve,atrial fibrillation).
- It is a rat poison.
- It counteracts factors: II, VII, IX & X (remember them as: 1972).
- The one responsible for the mentioned factors is Vitamin K, so warfarin counteracts the effect of
vitamin K.
- Its effect start after 12 hours and lasts for 72 hours.
- Tested by: PT (11-15 sec) and INR.
- If we apply APTT, it can be prolonged or normal. While the PT is definitely prolonged.
Dental aspect:
- Do not interfere with therapy. You should never stop the warfarin unless you consulted the physician.
- Simple extractions: INR up to 3.5 there is a doubt about this value as the doctor advise Always be

vigilant, you have to make sure that you are treating the patient safely, so 2.5 is accepted. (remember:
normal INR=1)
- Avoid regional block injections.
- Minimize trauma.
-Use topical haemostatic agents (as tranexamic acid).
- Local measures to stop post-operative bleeding (called: surgicel) include: packing with a haemostatic
dressing, suturing and pressure.
-Again, Warfarin anticoagulation effect is derived from its ability to prevent the metabolism of vitamin
K to its active form, which is needed in
-the livers synthesis of clotting factors II, VII, IX & X.

Disseminated Intravascular coagulation
- Patients with DIC have bleeding and coagulation disorders.
- Cause: it can be anything and may affect anybody.
- DIC may result from sepsis (severe infection in the blood), trauma and sometimes occurs with
obstetric complications
-DIC contribute to unorganized clotting factors in the body.
- As a result the clotting factors will aggregate in different sites (unwanted sites) resulting bleeding
disorders and hyper-coagulopathy at the same time.
- DIC occurs in Acute & chronic forms:
* Chronic DIC: patients can live with it and hypertension is characteristic.
* Acute DIC: is very difficult to manage and 50% of Acute episodes of DIC will die.

Principles Of Surgery

-Human tissues have genetically determined properties that make their responses to injury fairly

-decisions concerning a maxillofacial surgical procedure should be made long before the administration
of anesthesia.
-The decision to perform surgery should be the culmination of several diagnostic steps.
- In the analytic approach the surgeon first identifies:
1-various signs and symptoms and relevant historical information
2-using available data and logical reasoning
3- the surgeon establishes the relationship between the individual problems.
Lets say we have a patient that requires wisdom tooth extraction.
1- history , proper physical examination , radiographs and lab tests.
2- differential diagnosis.
-All the differential diagnoses are placed from the most probable to the least. Each diagnosis is
excluded one by one to reach the definitive diagnosis.

The initial step in the presurgical evaluation is:

1-the collection of accurate and pertinent data: This is accomplished through patient interviews;
physical, laboratory,and imaging examinations; and the use of consultants when necessary.

-Patient interviews and physical examinations should be performed in an unhurried, thoughtful
- The surgeon should not be willing to accept incomplete data, such as a poor-quality radiograph,
-data must be organized into a form that allows for hypothesis testing
-By using this method, along with the knowledge of which diseases we know if the surgery is indicated.
2- Clinicians also must be thoughtful observers:
- they should note all aspects of its outcome to advance their surgical knowledge
-improve future surgical results.
-This procedure should also be followed whenever a clinician is learning about a new technique. 3-
clinician should practice evidence-based dentistry by evaluating the purported results of any new
technique by weighing the scientific merit
- scientific methods are violated by the unrecognized introduction of a placebo effect, observer bias,
patient variability, or use of inadequate control groups.

-basic necessities required for oral surgery are two
(1) adequate visibility which depends upon three factors:
*adequate access which requires the patient's ability to open the mouth widely.
-Retraction of lips, cheeks and tongue
- the creation of surgical flaps
*adequate light: light source must continually be repositioned, or the surgeon or assistant must avoid
obstructing the light or use a headlight
*surgical field free of excess blood and other fluids: High volume suctioning with a relatively small tip
can quickly remove blood and other fluids from the field
(2) assistance: the assistant should be sufficiently familiar with the procedures being performed to
anticipate the surgeon's needs.

-Aseptic technique : minimizing wound and surgical field contamination
-this can be done by using antiseptic and disinfectant solutions , wearing aprons and gloves, and
placing the sterilized instruments on the sterile sheet.

Operative techniques
1) Each surgical procedure is started by: 1) doing an incision then2) retraction of soft tissue flap
to gain access and some surgeries require removal of bone then 3) delivery of the tooth or root
then4) debridement and irrigation is done to smoothen sharp bony edges then 5) suturing and
6)post operative care of the patient.


Few basic principles are important to remember when performing incisions. Which are:

1- a sharp blade of the proper size should be used.

*The blade used is fixed on the scalpel. In oral surgery the scalpel used is number 3 scalpel.
*The rate at which a blade dulls ( becomes not sharp) depends on the resistance of tissues through
which the blade cuts.
-Bone and ligamental tissues dull blades more rapidly than does buccal mucosa. Therefore the surgeon
should change blades whenever the knife does not seem to be incising easily.
*These are some types of blades used in oral surgery:

2-Use a single firm continuous stroke when incising.

-Repeated incisions are not allowed because they cause damage to blood vessels and soft tissue which
increases bleeding and may complicate our surgical treatment.

*holding the scalpel is done using the pen grasp, for more control and tactile sensitivity, and only the
wrist should be moved not the whole forearm.

3-the surgeon should carefully avoid cutting vital structures when incising And the surgeon must
incise only deeply enough to define the next layer .
a- incisions in the buccal area of the lower premolar should not be done to avoid injuring the mental
nerve so vertical releasing incision should be distal to the tooth away from the mental nerve area
b-Incisions in the lower wisdom teeth area lingually should not be done to avoid injuring the lingual
nerve which is covered only by soft tissue in this area.
c-when using a scalpel the surgeon's focus must remain on the blade to avoid accidents
4- incisions through epithelial surfaces that the surgeon plans to reapproximate should be made
with the blade held perpendicular to the epithelial surface ( 90 degrees) .
-squared wound edges that are both easier to reorient properly during suturing and less susceptible to
necrosis of the wound edges as a result of ischemia
-any oblique incision will cause undermining of the edges which will compromise the blood supply
and subsequently interfere with wound healing.
5- incisions in the oral cavity should be properly placed.
It is more desirable to incise through attached gingiva and over healthy bone.
-not cross the canine eminence because this will cause dehiscence and separation of the flap margin
Blade number 11: used to do an incision in an abscess to drain it.
Blade number 15: most commonly used

Blade number 10: similar to number 15 blade but larger, usually

used by general surgeons to do excisions extraorally.
Blade number 12: posterior area of the oral cavity, especially in
the maxillary tuberosity region ( curved)

later on because its a prominent area,
2- for a more esthetic outcome , the incision should not be done on the mid portion of the dental papilla,
it should be either including it or mesial or distal to it but not in its middle
-Properly placed incisions allow the wound margins to be sutured over intact, healthy bone that is at
least a few millimeters away from the damaged bone, thereby providing support for the healing wound.
Incisions placed near the teeth for extractions should be made in the gingival sulcus, unless the clinician
feels it is necessary to excise the marginal gingiva or to leave the marginal gingiva untouched..
Flap Design
Surgical flaps are made to:1- gain surgical access to the field , for example in order to extract an
impacted wisdom tooth I have to make a flap to gain access to it. 2- Or to move tissue from one
place to another.

** Several basic principles of flap design such as : 1-making the flap with an adequate size and 2- a full
thickness flap passing through mucosa, submucosa, and periosteum must be followed to prevent the
complications of flap surgery, which are:1- flap necrosis, 2-dehiscence, and 3-tearing.
1- flap necrosis
Flap necrosis can be prevented if the surgeon attends to four basic principles.
First, the apex (tip) of a flap should never be wider than the base, unless a major artery is present in the
base. Flaps should have sides that diverge ) ) moving from the apex to the base in order not to
compromise the blood supply of the flap.
Because the source of blood supply to the flap is the periosteum which is found in the area where the
base of the flap

This is a wrong flap design, the red area will have This is the right Flap with the
base wider than

Second, generally the flap base dimension (x) must not be less than height dimension (y), and
preferably flap should have x = 2y, the width is always larger than the length.
when possible, an axial blood supply should be included in the base of the flap, for example a flap in
the palate should be based toward the greater palatine artery .

An example on this is the cases of oroantral communication., many techniques are used to close this
communication like1) buccal advancement flap and 2) palatal rotational flap. but we dont do a vertical
releasing incision for closure because we may hurt the greater palatine artery.
In the palatal rotational flap, We do two incisions that are long enough and rotate the flap to close the
fistula, by this the greater palatine artery will be included in the flap.
Fourth, the base of flaps should not be excessively twisted, stretched, or grasped with anything that
might damage vessels, because these maneuvers can compromise the blood supply feeding and draining
the flap.
-The reason that may require the use of over retraction is: inadequate flap size, so your flap should be
big enough from the beginning .
2-Flap dehiscence
Flap margin dehiscence is the separation between flap margins after suturing And it is prevented by:
1) approximating the edges of the flap over healthy bone, 2)by gently handling the flap's edges,3) and
by not placing the flap under tension which may lead to necrosis. Dehiscence exposes underlying
bone, producing pain, bone loss, and increased scarring.
*incision should be 5-8mm away from the surgery area so that later on suturing of the flap happens
on healthy bone and flap dehiscence is prevented.
3-Flap Tearing
Tearing of a flap is a common complication of the inexperienced surgeon who attempts to perform a
procedure using a flap that provides insufficient access. Because a properly repaired long incision
heals just as quickly as a short one, it is preferable to create a flap at the onset of surgery that is large
enough for the surgeon to avoid either tearing it or interrupting surgery to enlarge it.

The difference between an acceptable and an excellent surgical outcome often rests on how the surgeon
handles the tissues. The use of proper incision and flap design techniques plays a role; however, tissue
also must be handled carefully. Excessive pulling or crushing, extremes of temperature ( like drilling in
the bone without using copious amounts of irrigation), desiccation, or the use of unphysiologic
chemicals ( like using hydrogen peroxide instead of normal saline for irrigation by mistake) easily
damage tissue .

Prevention of excessive blood loss during surgery is important for preserving a patient's oxygen-
carrying capacity. However, maintaining meticulous hemostasis during surgery is necessary for other
important reasons
1-decreased visibility that uncontrolled bleeding creates.
2-formation of hematomas ( collection of blood inside tissues). Hematomas place pressure on wounds,
decreasing vascularity; they increase tension on the wound edges; and they act as culture media,
potentiating the development of a wound infection.

Techniques for Promoting Wound Hemostasis (the process that stops bleeding):
1) by assisting natural hemostatic mechanisms. This is usually accomplished by placing pressure on
bleeding vessels which causes stasis of blood in vessels, and promotes coagulation. A few small vessels
generally require pressure for only 10 to 30 seconds, whereas larger vessels require 10 to 20 minutes of
continuous pressure.
2)by suture ligation.
3)placement of a pressure dressing over the wound. This creates pressure on the small vessels that were
cut, promoting coagulation.
4)Placing vasoconstrictive substances, such as epinephrine, in the wound or by applying procoagulants,
such as commercial thrombin or collagen, on the wound.
5) the use of heat to cause the ends of cut vessels to fuse closed (thermal coagulation). this is done by
using a device called
Microcautery , Heat is usually
applied through an electrical
current that the surgeon
concentrates on the bleeding
vessel by holding the vessel
with a metal instrument, such
as a hemostat, or by touching
the vessel directly with an
electrocautery tip.

Dead Space Management
Dead space in a wound is any area that
remains devoid of tissue after closure of the
wound. Dead space is created by either
removing tissue in the depths of a wound or by
not reapproximating all tissue planes during
closure. Dead space in a wound usually fills
with blood, which creates a hematoma with a
high potential for infection.
Decontamination is easily accomplished by repeatedly irrigating the wound during surgery and closure.
Irrigation dislodges bacteria and other foreign materials and rinses them out of the wound. Irrigation can
be achieved by forcing large volumes of fluid under pressure on the wound using a syringe. Although
solutions containing antibiotics can be used, most surgeons simply use sterile saline or sterile water.

Wound debridement is the careful removal from injured tissue of necrotic, foreign, and severely
ischemic material that would impede wound healing.


Edema is an accumulation of fluid in the interstitial space because of transudation from damaged
vessels, and lymphatic obstruction by fibrin .

the greater the amount of tissue injury, the more loose connective tissue that is
the greater the amount of edema contained in the injured region, the more edema is
present. * *For example attached gingiva has little loose
CT, so it exhibits little tendency toward edema.
While the lips , cheeks,and FOM contain large
amounts of loose CT and can swell significantly
**Edema is a common complication after surgical extractions, but sometimes it may also happen after
simple extractions if the extraction was traumative.
** The dentist can control the amount of postsurgical edema by performing surgery in a manner that
minimizes tissue damage.
**also ice packs can be used, we ask the patient in the first day of surgery to put ice from 5-10 minutes
every 3-4 hours, which can decrease the vascularity in that area and decrease edema.
**We can use medications, mainly high dose short term corticosteroids.In general we use
Dexamethasone which is an anti inflammatory drug which has the ability to decrease edema.
Proper wound healing depends on: a patient's ability to resist infection, to provide essential nutrients
for use as building materials, and to carry out reparative cellular processes. Numerous medical
conditions impair a patient's ability to resist infection and heal wounds. These include conditions that 1-
establish a catabolic state of metabolism, 2-that impede oxygen or nutrient delivery to tissues,3- and that
require administration of drugs or physical agents that interfere with immunologic or wound-healing
** Examples of diseases that induce a catabolic metabolic state include:
1) poorly controlled insulin-dependent diabetes mellitus,
2) end-stage renal or hepatic disease,
3) and malignant diseases.
**Conditions that interfere with the delivery of oxygen or nutrients to wounded tissues include:
1) severe chronic obstructive pulmonary disease (COPD),
2) poorly compensated congestive heart failure (hypertrophic cardiomyopathy),
3) drug addictions, such as ethanolism.
** Diseases requiring the administration of drugs that interfere with host defenses or wound-healing
capabilities include:
1) autoimmune diseases for which long-term corticosteroid therapy is given 2)malignancies for
which cytotoxic agents and irradiation are used.

Variables that help determine
the degree of postsurgical
Amount of tissue injury
Amount of CT in the injured

The surgeon can help improve the patient's chances of having normal healing of an elective surgical
wound by evaluating and optimizing the patient's general health status before surgery. For malnourished
patients, this includes improving the nutritional status so that the patient is in a positive nitrogen balance
and an anabolic metabolic state.

Complicated exodontia
-All exodontias are surgical though the term simple is widely used.
- Simple extraction = Intra-alveolar extraction = Closed extraction = Uncomplicated extraction.
- Surgical extraction = Trans-alveolar extraction = Open extraction = Complicated extraction.
-simple extraction is a deceiving term though its used, its better to call it closed extraction.
Pain and Anxiety (anesthesia and sedation, respectly):
*Local Anesthesia Most commonly used is Lidocaine acts for about 2-3 hours (xylocaine, lignocaine
are other names for lidocaine).
when do we use lidocaine?
-Maxillary infiltration anesthesia it takes a rapid onset of action(Kick-off) and it lasts for a shorter
time (shorter duration of action).
- I.D Nerve Block it takes more time to kick-ofF and it wears-off slowly (longer duration of action).
-first tissues to be anesthetized are soft tissues then bone and teeth and, the first tissues to wear-off
are the soft tissues then the bone and teeth.

-Sedation : whenever the patient is thought to be anxious and difficult to manage.
-sedatives are not given to control pain, but they are used to reduce stress, and helps to induce
- how were going to make the patient relaxed? We give him Benzodiazepine like:
*Midazolam (I.V) and its given 1ml per kilogram (this is the maximum that can be given),
* diazepam (Valium) orally
- nitrous oxide (N2O) is also used, mainly with children.

The Indications & Contra-indications for Extraction:
1.Non- restorable teeth
2.carious teeth
3. remaining roots
4.severely periodontally-involved teeth (severely mobile teeth),
5.referral for orthodontic treatment
6.prosthetic rehabilitation
7.associated pathology

1-Radiotherapy (the risk of developing osteoradionecrosis), after some sort of level of radiation dose,
not every patient on radiotherapy ,the first thing we need to know about radiotherapy:
*Location-if the therapy is in the head and neck region,close to the area of extraction then the extraction
is contraindicated.
2- Malignancy at the site, if a tooth is to be extracted and there is an associated malignancy, we
should make a comprehensive management e.g. not simply extract a carious tooth associated with a
big oral cancer, because if the dentist extracted the tooth he would disseminate the cancer,
3-if there is an infection or abscess the tooth should be treated either by extraction or incision and
drainage AFTER that antibiotics are administered (EXCEPT FOR)

WHICH THE TOOTH (with infection) IS NOT EXTRACTED (a contraindication for extraction). So, the
moderate to severe pericoronitis is the only indication for giving antibiotics BEFORE taking the tooth

4-Tooth is close to vital structures :
*In the mandible, we concern about two main structures :
1.lingual nerve
2.mental nerve,
3. I.D nerve
* in the maxilla
1.maxillary sinus
2.greater palatine bundle (neurovascular), especially the greater palatine vessels.
Closed Extraction VS. Opene Extraction
Closed extraction:
- Simple extraction its a surgical extraction but its a closed extraction
-closed means that we dont need to open a flap.
Open extraction:
-We open a flap and expose the bone, tooth and the periodontium , hence open extraction. - its also
called transalveolar meaning that its not closed and we try to take the tooth out through the
- closed extraction doesnt mean its more conservative
- when the case needs opening a flap, opening a flap is more conservative if we dont the associating
and surrounding tissues will undergo severe trauma e.g. bone fracture by using some instruments.

The indications for open-extraction :
1- Failed closed-extraction
2- If theres dense bone surrounding the tooth:
*racial (e.g. black people usually have denser bone than other races)
*anatomical (e.g. wisdom tooth surrounded by buccal dense bone)
*pathological :
-Pagets disease of bone in which there is dense bone and theres hypercementosis
3- an old patient who has one standing tooth the bone surrounding that standing tooth will be dense,
so this tooth is anchored strongly in the bone.
4- Funny roots : ankylosis, hypercementosis (as in Pagets disease or in old people with
standing molars especially if theyre not used), and dilacerations.
5- Lose condyles, as in EhlersDanlos syndrome or Marfan syndrome (connective tissue
diseases), in general people with connective tissue diseases has lax muscles and lax joints or
ligaments, in people with lose condyles, when closed extraction is used it might cause TMJ
6- Heavily decayed teeth
7- Pneumatized sinuses, an enlarged sinus, as if the upper first molar has been extracted for a long
time, the space of the tooth in the bone will be occupied by the sinus so the floor of the sinus could
be easily fractured resulting in oro-antral communication but if a planned open surgical extraction
was done, some bone layers wouldbe removed little by little without applying much force preserving
the integrity of the sinus. (
-The palatal root of the upper first molar is very close to the sinus and can be in the sinus itself,
penetrating the sinus floor and covered by the sinus membrane).
Steps for The Surgical (Open) Extraction of Teeth:
All of the following steps are vital and care must be taken of them
1- MPF (muco-periosteal flap).
2- Removing bone.
3- Delivery of the tooth (how to deliver or take the tooth out after doing the flap and bone removal).
4-Irrigation and Debridement
5- Closure.
6- Post-op. care.

1-The muco-periosteal flaps three types:
1- envelope flap in which the gingiva over the alveolar crest next to the teeth is only incised (from the
crevicular side of the gingival- One-sided flap, without releasing incision.
-releasing or relaxing incision makes the flap able to be opened wider.

2-two-sided flap = triangular flap = 3 cornered flap = envelope flap with one releasing incision.
3-three-sided flap = Rhomboid flap = 4 cornered flap = envelope flap with two releasing incisions.
4- crestal flap in edentulous patient on the alveolar crest, like the envelope flap but when there is no

Envelope flap: the incision is done on the sides of the teeth and there is no releasing or relaxing
incision, so good access should be obtained.
- good envelope flap incision is two teeth anterior and one tooth posterior to the area to be worked
on,this is to make sure that the tissues can be retracted easily and nicely without making any tears.
-Triangular flap, the incision is extended one tooth anterior and one tooth posterior to the tooth in
question (not two teeth anterior like the envelope flap) because there is a releasing incision, the
mucosa will be elevated or retracted away.

- long incision heals just like the short incision as long as its kept clean, and treated properly.
- small inadequate incision is going to be retracted more to make access and this will cause the
incision to be torn and the healing of such an incision is very slow

Triangular flap

Four-sided flap its better to go one tooth anterior and one tooth posterior, some argue that its not
wrong to make the incision just around the tooth in question.
-The base of the flap must be wider than its apex to maintain good blood supply to the flap.

A.Doing the incision around the teeth starting from the area which is more difficult to be seen to the
area which is easier to be seen (i.e. posterior to anterior)
- if the incision is started from anterior, the blood will go to posterior making the area posterior (which
is already difficult to see) even more difficult to see.
B. Doing the incision parallel to the tooth as much as can be especially in envelope flap or
incisions next to the teeth.
C. Doing the incision firmly down to the bone using continuous one stroke (not short
intermittent ones) using the tip of the blade
D. If a vertical or releasing incision is going to be done, tissues should be bit tight by retraction, so the
result is cleaner and less tissues are cut.
E .Reflection then retraction of the flap, first the interdental papillae is pried then the rest of the flap
is elevated after reflection of the flap, then retractors are used to make sure that the flap is away from
bone e.g. Austin retractor .
2-Removal of bone, sometimes reflection of the flap by its merit is enough e.g. clarifying a certain area
where the extraction forceps or other instruments such as Coupland's elevator can be applied and no
bone is needed to be removed.
- most of the times when a flap is opened, there is a need to remove bone, bone can be removed either by
a chisel or a bur, chisel might traumatize tissues hit, the bur is more conservative.
*advantages of bone removal:
-Exposure of a part of the tooth makes it easily elevated, by buying a point of application to the
elevator, also bone removal may create a space for a tooth to be displaced, sharp edges and loose
fragments of bone can be removed, the socket can be reduced,and to ensure that there is no
prosthetic problem(mandibular torus).
*two methods of taking the bone out:
1- postage stamp method: the site of bone removal is delineated by the bur (making holes around the
area) then these holes can be easily matched or connected together making the bone removed in the right
amount and the right way.
- The holes in the postage stamps facilitate their separation likewise the postage stamp method of bone

2- Guttering: removing layers of bone until the wanted level is reached so that the instrument that is
wanted to be applied can be used well, bone can be removed in a way starting from above and going
downwards little by little until the level which makes the application of the forceps possible is reached.
-general rule bone can be removed up to two thirds of the root (only leaving the lower third)-but its not
always necessary.
- bone is removed until its thought that the tooth can be taken out, so conservativeness implies always,
that is little bone is removed then the tooth is tried to be taken out ,not to remove the whole amount of
bone then trying to take the tooth out.
-Always done with proper lighting and proper suction its most crucial step because the tooth can be
easily dislocated
- Delivery must be done with the extraction forceps.
-The most important thing we cant use elevators for delivery.
4-Irrigation and debridement
*Irrigation: decreases the rate of retention of fragment , increases the rate of healing , reduces the pain
after extraction, and irrigation with like normal saline
- For removing fragments you can use:
1- irrigation
2- cryer elevator
3- apexo elevator
4-endo file
- other option is leaving the fragment . sometimes if leaving the fragment is better then take it out.
-now there are an requirements for that :
1-when the risk benefit ratio favors leaving the fragment
2-when I will cause more destruction by getting the fragment out
3-when I will traumatize vital structure like pushing the root between the maxillary sinus and causing
chronic sinusitis .
4-the remaining root should be less than one third of the original root
5-the remaining root shouldnt be infected
*debridement : is one of the benefits of flushing during irrigation , you will take any loose bone out . -
by handpiece instrument with normal saline.
-we can debride the sharp edges by file or large round bur.

5-Suturing : the aim of suturing is placing the flap in its original position .
-suturing isnt covering every thing by the flap
-dont make any sort of retention on the edges of the soft tissue because this can cause necrosis.
-Sometimes we use suturing to hold the clot, mainly when we extract an upper six and we suspect that
there is an oroantral communication between the sinus and the oral cavity , to stabilize the clot and
prevent communication
Types of sutures:
-two types:
1-Resorbable: the body can resorb it by enzymes
types of resorbable sutures are :
*gut ( (sutures : natural we can take it from sheep/goat (mainly) and cat .
-The problem of Gut sutures (natural) that it can be easily get resorbed so they treat this naturally
resorbable make it stay for longer time.
*Polygalactic and polygalactin (Vicyrl) : synthetic , its stronger and last for a longer time, and its
most commonly used now because its:
-strong and stay 1 or 2 weeks
-you dont need give a patient appointment for review .
-studies said there is slight difference between resorbable and nonresorbable in hygienic.
- so the nonresorbable is more hygienic but the patient will need a review appointment.
Now when we look to this pic below we should be able to know :
arrow : the length of the thread (45 , 75 )
arrow: the name of the suture
arrow : the tip of the needle , it might be round or cutting or reverse
cutting . the best for oral surgery is reverse cutting ,bcz the cutting
edge of it is straight and will not tear the flap
arrow : the curvature of the needle ,it will detect the ark of the needle
and its part of a circle ( 3/8 circle , 1/2 circle )
-Some company will write if the suture is monofilament or multifilament .
2-Nonresorbable :
-silk : its used in the oral cavity and we said its more hygienic than resorbable .
-nylon : its multifilament (it has 2 types multi and mono filament) like threads that are tightened
* multifilament is always less esthetic than monofilament

*on the skin we use monofilament not to cause big scar at the area of suturing .
-polyester and polypropylene : monofilament so we can use them extraorally .
Technique of suturing :
Using tweezers and needle holder :
-Needle holder :should be held by putting the thump in the first ring of the holder and the ring finger on
the second ring
1-Now we catch the last 2/3 (or 1/3) of the needle by the tip of the needle holder
2-the needle should be 90 degree with the needle holder
3- we should start from the mobile part of the flap not the nonmobile and the needle should go in the
flap vertically and go out vertically by the tweezers
4-knot ( (. but how much knots should I do ??
-Every suture material have a special number of knots
- make sure that each knot is stable
- nylon needs 6 knots , vicryl needs 4 knots .
Sutures types:
A-interrupted suture (universal the most common type in oral surgery )
,every suture knot is alone .
B-continuous suture (running ) : we continue suturing all the way without
stopping, the good thing in continuous suture that its stronger than interrupted
suture but if one part is torn all the flap will open , not like in interrupted just
that torn area of the flap will open .
C-continuous locking : the aim of this suture is to make sure its
water dried , thats mean it close the flap in away that inhibit water to
go in it . ( this description is not real bcz it cant inhibit water from
going in but this description tell us how much this suture is tight ).
D-horizontal mattress : there are 2 lines on each side of the flap and
tightened in one side . they are horizontal on the flap . This suture will give good closure of small
E-vertical mattress : here there are 2 lines one of them near the edge of the flap and the other is
away and they are vertical on the flap .

6-post-operative care: this step is vital as extraction
-you should tell the pt that it might be pain and swelling
-prescribe analgesic for pain, and antibiotic for infection
-List of complications:
*Ecchymosis: blood accumulation(large hematoma),at site of extraction or outside.
*petechiae:small hematoma
*swelling: its something nomal you cant inhibit it but you can reduce it by:
-in extraction day : putting some cold compressors->Vasoconstriction decrease blood flow to the area-
>less edema
-one day after extraction : putting hot compressors->vasodilatation-> edema reduction.
-we can give anti-inflammatory(Steroids- Cortisol ) before procedure-> Dexomethasone.
*Trismus: reduction of mouth opening
-Muscle get spasmatic due to muscle manipulation
-Blood may get into muscles around the face causing inflammation
*Pt's food:
-First day: pt should drink soaps/fluids (not too hot) avoid solid food.
-the day after: pt should eat anything thats high in calories to recover soon.
*Oral hygiene:
1-Extraction area should be kept as clean as possible
2-pain should be controlled
3-Prevent infection by prescribing Antibiotics, only for immune compromised patients, even if its closed
4-recall appointment should be scheduled.

How to use elevators?
The blade should be wedged between tooth and the bone that its supported the same tooth.
-never rely on the adjacent tooth because you may luxate it.
Types of elevators:
1-Coupland elevator
2-Cryer elevator
3-Apexo elevator
4-Warwick James elevator

Multiple extractions:
-we should start by maxillary teeth because:
1- extraction of most of the upper is by bucco-paltal movement , the lower by some sort of vertical
movement so you can hit the upper if they were not extracted \
2- to prevent any blood or whatever from going down into the lower socket .

-The doctor prefer to start by the mandible because when we extract the lower teeth first, the blood will
go down and the area will be clear .

-we start extraction from posterior to anterior teeth except first molar and canine , so the extraction
sequence is like this :
(from left to right) 8 7 5 6 4 2 3 1
Why this sequence?
Because : first molar has big roots so when we extract the surrounding teeth we will have more space
and better manipulation , and canine has the longest root so we can manipulate it easily .

Third molar extraction
1-Surgical Flap : FULL Muco-periosteal flaps; meaning we reflect ALL the tissues
above the bone (mucosa, subcutaneous tissue & periosteum),
Three types of Muco-Perosteal flaps
1. Envelope flap
2. Two-Sided/Triangular
3. Three-Sided/Rhomboidal
-lingual retraction to view the anatomy lingually its used in all 3 types of flaps
mentioned above,
-lingual retraction can cause : Lingual paresthesia so use it only when its needed
Lingual Split Technique where the whole incision is done from the lingual side; and
a chisel is used to fracture the lingual plate (thin bone), it provides easy access to the
tooth and easy removal
-Technique :Lingual split is placing the chisel just lingual to the seven (2
Molar) and
lightly tapping the lingual plate to break it.
-wisdom teeth are usually located more lingually than the rest of the teeth
-DISADVANTAGE : very traumatic leading to a very high rate of lingual paresthesia.
-ADVANTGE: shorter operation time, taking less than 3 minutes instead of the usual
half hour.
2-Bone Removal: up till the level of the cement-enamel junction; in a process called
1- Guttering (ditch formation around the tooth)
2- OR complete bone removal buccally until the level of cement enamel junction.
- Use round bur for bone removal (smaller tip = better vision field)
-DONT use a fissure bur cause you wont have clear of a view due to the larger tip
-fissure bur is more useful when de-capitate/sectioning/cutting the tooth,cutting edge
is very thin, giving you better control.
-Bone removal is from the mesial to the distal except when we are removing bone
from the distal side of the tooth and pull mesially; this is for two main reasons:
1. To be able to see the area youre operating on
2. The lingual nerve is located disto-lingually to the wisdom teeth, any
slippage might lead to damage to the nerve.

3-Tooth Sectioning: cutting the tooth itself, sectioning may be:
Crown removal/separation from the roots
Sectioning the tooth into two pieces (as if you have two separate pre- molars),
and each half of the tooth is extracted separately.
4-Irrigation: after sectioning or removing the tooth
* main purpose of irrigation is to :
1-decrease the bacterial in the socket).
2-flush out necrotic tissue and debris,
*Irrigation alone has a very large effect on decreasing post-op infection
4- File and Debride the bone, getting rid of any sharp edges or bone spurs by burs or
bone files.
5- Suturing
6-Post-Op Sequela
What is the difference between post-op sequel and Post-op complications? Post-op
sequela means any expected/usual occur after operation in case of 3
extraction like:
2-stiffness : due to applying force to the muscles of mastication, leading to Mild
3- swelling : expected to increase up to 48hrs after surgery, after 48 hours it reaches
its peak size, then begins to decrease (usually swelling is completely gone after 5
4-moderate bleeding/oozing : is expected for the first 24hrs and anything above
24hrs is considered a problem.
- bleeding at first 24hrs is not a free flow bleeding, but instead a slight drop
-Profuse bleeding/active bleeding on the other hand is a sign of something wrong.
5-Pain: Any extraction (wisdom or other) is expected to lead to post-op pain its
maximum 12 hours post operation, after which it begins to decline so prescribe good

6-Post-Op Complications:
Complications only occur with some patients, and unlike post-op sequela they NEED
1-Swelling: If a patient comes to you 4-5 days after extraction with swelling, increased
temperature,exudates intra-orally Pt has post-operative infection
Tt: re-opening the flap, debride the area, irrigate and prescribe antibiotics.
-If swelling reach facial spaces of the neck-->Pt. needs hospitalization.
2-Fractured mandible: most sensitive part is the angle(sport injury)
Tt: reduce the fracture, by re-opening the flap and placing a metal plate on the
mandible joining the fractured halves.
3-Fractured Alveolus/Tuberosity: maxillary 3
molar, it is very close to the maxillary
tuberosity; due to much force is applied (or the tooths roots are flared).
-if the tuberosity itself is broken and becomes detached
Tt: complete removal of the tuberosity with the tooth and the flap sealed
-Complications : Maxillary sinus communication with oral cavity.
-If while extracting you feel that the alveolus fractured/cracked under force (with
detachment) you should close the flap without extracting the tooth.
-Wait around a month for the bone to heal, then refer the patient to a surgeon.
-remember that surgical extraction is conservative extraction).
4-Dry Sockets: high percentage of occurrence when wisdom teeth are extracted, 3-
*The result of the lysis of a blood clot, before it is replaced with the granulation
tissue, meaning that the bone is bare.
- occurs only after 72 hours post-extraction accompanied by a very bad smell/odor.
-Causes of Dry Socket
1-Digestion of blood clot by oral bacterial (streptococci)fibro-lysis of clot
2-Salivary enzymes may digest/dissolve the clot
3-Tissue plasminogens may dissolve the clot
-Factors I ncreasing Dry Socket Occurrence:
1- Smokers within 12 hours of extraction, smoke itself is a clot fibrinolytic.
2- Oral Contraceptive- have fibrinolytics in them, cause dense bone in the jaw
3-Increase in LA- leads to vasoconstriction->low blood supply->low clot formation
4-Dense bone (Af r i c a n - Ame r i c a ns ) : very dense bone->decrease in bone
marrow/vessels->low vascularity->low blood clot formation.

-Prevention of Dry Sockets:
-giving prophylactic or post-op antibiotics leads to a decrease in the occurrence of dry
- Administered antibiotics can either be:
1-local/topical -tetracycline INSIDE the socket
2- pre-op antibiotics-amoxicillin-we always give penicillins which are higly effective
against streptococci viridians
- except in peri-chorinitis where metro-nidazole is given
- best way to prevent dry socket is proper irrigation after extraction
* irrigants : normal water or saline, as long as it properly flushes the socket.
-Treatment of Dry Sockets:
1-re-irrigate the socket
2- debride gently debride the area
*rough debridement will lead to removal of any blood clots which is counter-
3-Alveo-gel (a eugenol/sedative based gel) placed inside the socket as a sedative
only and replaced every few days,it only decreases the pain.
* Alveo-gel should ONLY be used when the pain cannot be controlled with
analgesia, as it is considered as a foreign body and may lead to delayed healing of
the wound.
5-Nerve Disturbance:
*Temporary nerve disturbance as a post-op extraction is 3%
* PERMANENT nerve disturbance is very rare, less than 0.01%
* nerves affected : Lingual, ID nerve, Long Buccal or the nerve to the MyloHyoid.
1-tooth itself was close to the nerve according to Roods and Shehap classification.
2- compression injury (downwards pressure onto the ID canal during)
3-Canal damage due to complete bony impaction while sectioning the tooth.
6-Displacement of Wisdom tooth during Extraction:
Displacement in the Mandible:
1-towards the lingual pouch (beneath the mandible, in the sub-mandibular space).
The treatment of this displacement is:
* Take a Radio-Graph
* Inform the patient
* Leave the tooth in its position
* Prescribe antibiotics

* Transfer to a surgeon- the surgeon will usually wait a month to allow fibrosis of the
tooth for stabilizing it and making it easier to remove.
Displacement in the Maxilla:
Into Maxillary sinus or the infra- temporal space;
*radiographing the tooth
*inform the patient
* transfer him to a surgeon.
-Surgeon will first take a CT scan of the tooth and wait 2-3 weeks before operating
- the surgeon can either leave the tooth or remove it, depending on the patients
- Infra-Temporal space contains the vessels of the external carotid artery, surgical
operation difficult and can lead to severe bleeding.
*The infra-temporal space is more dangerous than the lingual pouch and maxillary
sinus, therefore you should always weight the benefits vs. risks before operating.
*If the tooth is lodged in the sinus the extraction of the tooth is called a Caldwell-
Luc operation, where the tooth is extracted from the sinus via the vestibule.
7-Swallowing/inhalation of the tooth:
*Swallowing the tooth: not major complication, it will leave the body throughGIT.
*Inhalation of the tooth will lead to it ending up in the lungs, where it can cause a Lung
*Removal of an inhaled tooth only by bronchoscopy.

Impacted third molar
-every impacted tooth is unerupted tooth but not every unerupted tooth is an impacted
- an impacted teeth is simply a tooth that has passed the time of eruption and it cant erupt
any more
-Third molar extraction:

There is a group of people called NICE Stands for National Institute For Clinical Excellence
t h e i r responsible for putting an extraction guidline:
1. If there is evidence of pathology like a cyst or tumor
2. A tooth that is involved in osteomylitis most commonly happen in mandibular molar
region due to deep carious lesion.
3. Incomplete tooth fracture was the apparent cause of this type of periapical pathosis.
4. teeth are impeding surgery, problems in opening the mouth some,inhibited jaw
movements anteriorly or posteriorly.
5. Pericoronitis: infection in the soft tissues that surround partially erupted wisdom tooth
due to food and bacteria impaction.
-Result in bad breath, pain, swelling and trismus
- The infection can spread to involve the cheek and neck
-Once the initial episode occurs, each subsequent attack becomes more frequent and
more severe
*MILD PERICORONITIS: swilling in the mouth.
-Treatment- irrigation and OHI
*MODERAT PERICORONITIS: swelling gets bigger and a limitation in mouth opening
*SEVERE PERICORONITIS : severe trismus and signs and symptoms of infection redness
,malaise, pain that gradually increase till it reaches to its severe stage.
-infection starts to convert itself to an abscess that will start spreading in submassetric
(space closed by massetric and buccinators muscles), it diffuse to the sulcus near 6 or 7
which we called migratory abscess of pericoronitis.
-Treatment : in moderate and severe pericoronitis we need to give antibiotic and the
eventual solution is extraction but after the episode of pericoronitis is resolved not
-according to NICE guideline pericoronitis is considered as indication for extraction if it
comes twice or more than twice a year.
6. Caries
7. As a cause of periodontal disease to the adjacent tooth

8. resorbtion to the 2
9.. Prosthetic reasons "complete denture"ridge will resorb and the tooth will appear
10. orthodontic reasons
11. Socio economic reasons just to avoid any unexpected complications
12.unexplained facial pain ,this for small percent1-2% of people not always right they may
have TMG dysfunction syndrome that explain that pain
13. prevention of jaw fracture usually wisdoms are found at the angle of the mandible
wisdom's extraction to lay down bone at the area of extraction.

1. Extreme age: medical problems or thin mandible.
2. medically compromised patient:
*systemic diseases
*bleeding problems
*local factor like radiotherapy
*tumor: if the tumor is related to specific tooth we remove both the tumor and the tooth , but in a
case that the patient has a tumor in the neck we dont do extraction to avoid spreading the
3. potential damage to vital structures like ID canal, mental foramen.
4.parasthesia to the nerve: to avoid parasthesia we do decavitation to the tooth by
removing the crown and leaving the roots as not to cause injury.
- in the case of the upper were its closed to the sinus or infratemporal space we dont
extract it ,we give antibiotic if its inflamed and we treat it conservatively.
Assesments :
1- Operative assessment related to patient itself
2- Local assessment related to the tooth itself
* Access
*Number and shape of roots
*Bone texture
*Tram line ( ID canal)

operative assessment related to patient itself:
-taking history and whats we called general assessment, like the patient age and
- stress is the main problem in extraction not pain
- Extraction with sedation either with LA or under GA decided according to pt. personality
and difficulty of the procedure.
-if the patient is frightened his pain threshold will be very low so we have to use sedation so
either LA with sedation or GA (More details later on)

Local assessment related to the tooth itself:
1-Access and width of mouth opening is appropriate for such a procedure (rima oris in Latin):
PELL and GREGORY put a classification for wisdom teeth it applies for mandible and maxilla
-Tow types of classes:
1-class1,2,3- applies only for lower wisdoms-related to access
2- classA,B,C- applies for upper and lower-related to depth.

Class 1,2,3 : position of the third molar related to Anterior border of the ramus
*Class 1: the tooth is found completely anterior to the anterior border of ramus of the
*Class 2: the tooth is found in the middle, part of it is found anterior to the anterior border
of the ramus and the other part is posterior to the anterior border of the ramuss
*Class 3: the entire tooth is found posterior to the anterior border of the ramus.

Winter's classification based on the inclination of the impacted wisdom tooth to the long
axis of second molar.
-Three lines (white line ,amber line, red line)
*White line : drawn along the occlusal surfaces of the erupted mandibular molars & extended
over the 3rd molar posteriorly
-Indication: the difference in occlusal level of the 1st & 2nd molars & the 3rd molar.
*Amber line: represents the (height of the) bone level, drawn from the surface of the
bone on the distal aspect of the 3rd molar (or from the ascending ramus) to the
crest of the inter-dental septum toward the 1st& 2nd molars.
- Shows bone level thats covering the 3rd
molar and gives some indication to the
amount of bone to be removed.
*Red Line : imaginary line drawn
perpendicular from the amber line to an
imaginary point of application of an
POA: mesial aspect of the impacted tooth
(unless, it is the disto-angular impacted
tooth where the application point is the distal cemento-enamel junction).
- The red line indicates the amount of bone that will have to be removed before
elevation of the tooth ie. the depth of the tooth in the jaw
-Extraction difficulty increases as the red line become longer.
Winter's Classifications are:
to differentiate between them we draw a line on the long axis of the next-door tooth
the 2
molar and a line on the long axis of the 3
and we check the angle between

2- depth of the tooth inside the bone.
-Pell and Greogory class A,B,C.
*Class A : The occlusal plane of the
impacted tooth is at the same level as the
occlusal plane of the 2nd molar. (The
highest portion of impacted 3
molar is
on a level with or above the occlusal
*Class B : The occlusal plane of the
impacted tooth is between the occlusal plane& the cervical margin of the 2nd molar. (The
highest portion of impacted 3
molar is below the occlusal plane but above the cervical line
of the 2nd molar).
*Class C : The impacted tooth is below the cervical margin of the 2
molar. (Thehighest
portion of impacted 3rd molar is below the cervical line of the of 2
90 degrees angle long axis is horizontal
Mesio-Angular. The impacted tooth is tilted toward the
second molar, in mesial direction
Disto-Angular. The long axis of the 3rd molar is
angled distally / posteriorly
VerticalLines are parallel

Note that its only the depth that is changing not the distance from the anterior border of the
ramus as in Class1,2,3

- Obliquity: generally most of the cases third molar positioned lingual to the rest of the teeth.
-Buccal / Lingual Obliquity:In combination with the above the tooth can be buccally (tilted
towards the cheek) or lingually (tilted towards the tongue) impacted, we call it bucco or
linguo-version tooth.

3. number and shape of the roots
-one root and its conical in shape: easy extraction
-If we have a tooth with 3 roots and they are erratic we
think of surgical extraction(Flap)
-Sometimes the problem is with the 2
molar, like we can cause : trauma ,fracture to the filling or
even fracture to the tooth itself
- always check third molar and next door tooth
-third molar with a big crown and small root is so difficult to extract
- when the tooth is not fully formed a follicle surrounds the crown so the tooth starts to rotate
in its place so its difficult to extract.
-If we have a second molar with a conical shape root and
we put the elevator between 7and 8 to extract the 8 we will definitely extract the 7 because it
will be easy to remove it due to the shape of its root
4. Assess bone texture for older people bone is much harder ,in sclerotic bone its more
difficult to take teeth out.
5. Assess the tram line- when you look at the x-ray you will find 2 lines for ID canal if they
are away from the tooth we are in the safe side ,extraction will not affect the nerve.

Rod and Shehap assement of the relation between ID canal and the mandibular third molar.

Fig.A Fig.B
Fig.E Fig.F Fig.G

Notching,Grooving and Perforation are true relations between -
IDC and wisdom tooth:
Notching: a radiolucent band at the apex of the roots, a break in
the continuity of the upper radio dense border, and narrowing at the
expense of the top of the canal .
Grooving: radiolucent band across the root above apex was
present with interruption of both superior and inferior borders of
the canal, and narrowing of the canal space.
Perforation : radiolucent band crossing the root above the apex
and loss of both superior and inferior borders of the canal at the area where they cross the root, with
constriction of the canal maximal in the middle of the root.
- Anesthesia full loss of sensation
-Hypoesthesia reduction in sensation still feel sensation
-Paresthesia is abnormal sensation there is something going wrong in sensation It is more
generally known as the feeling of "pins and needles
-Dysesthesia : unpleasant sensation they feel like electric shock after surgical procedure
abnormal sense of touch
-Hyperalgesia:increase response to stimulus which may be caused by damage
nociceptors or peripheral nerves.
We can extract third molars in THREE ways:
1-With LA
2-LA with sedation:
-Children : NO2 "Nitrous oxide".
-Adults: Midazolam or Diazepam5mg orally ,the day before surgery.
-Medazolam has an immediate effect, and more effective than Diazepam.
Why we give LA for pt. with GA?
2-Pre-empitive analgesia- anaesthetize C-fibers less pain when pt wakes up.